A survey of pharmacists in integrated care: Benefits, barriers, and facilitators of integration

INTRODUCTION

While models for pharmacist integration within primary care exist, less is known about their integration into primary care practices with already-embedded behavioral health. An exploratory survey was conducted to characterize examples of pharmacist integration into primary care systems providing dual behavioral and medical care.

METHOD

An electronic survey distributed through email listservs of four national organizations assessed pharmacists' background, training, practice setting and roles, and benefits and challenges of integration. Data were analyzed using descriptive statistics. A chi-square test was used to evaluate relationships between degree of integration and barriers.

RESULTS

The survey was completed by 119 pharmacists in primary care practices with integrated behavioral health. Pharmacists reported performing a variety of roles impacting quality of care, access to care, provider and patient satisfaction, and, to a lesser extent, care costs. Barriers to integration were common, including cost, underutilization, lack of role clarity for pharmacists, and space constraints. Mode of communication and workspace location were associated with pharmacist utilization and role clarity.

DISCUSSION

Pharmacists in primary care practices with integrated behavioral health reported improving care quality and access and supporting patient and provider satisfaction. Future work should survey others to confirm pharmacist self-perceptions. While fiscal justification of pharmacists on integrated teams remains challenging, utilizing shared workspace and creating mechanisms for in-person communication facilitate integration efforts by mitigating other barriers such as underutilization and lack of role clarity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cultivating patient-centered care skills through engagement in difficult conversations

BACKGROUND AND PURPOSE

Appropriately engaging with patients around sensitive, challenging, or uncomfortable topics, often termed "difficult conversations," is a facet of patient-centered care. Development of such skills prior to practice often occurs in the hidden curriculum. Instructors implemented and evaluated a longitudinal simulation-based module aimed at advancing students' understanding and abilities to use patient-centered care skills to navigate difficult conversations within the formal curriculum.

EDUCATIONAL ACTIVITY AND SETTING

The module was embedded within the third professional year of a skills-based laboratory course. Four simulated patient encounters were revised to increase opportunities to practice patient-centered skills during difficult conversations. Preparatory discussions and pre-simulation assignments delivered foundational knowledge, and post-simulation debriefing allowed for feedback and reflection. Students completed pre- and post-simulation surveys to measure understanding of patient-centered care, empathy, and perceived ability. Instructors assessed student performance in eight skill areas using the Patient-Centered Communication Tools.

FINDINGS

Of 137 students, 129 completed both surveys. Students' definitions of patient-centered care grew in accuracy and detail following module completion. Eight of the 15 empathy items were significantly changed from pre- to post-module, signifying enhanced empathy. Student perception of ability to perform patient-centered care skills significantly improved from baseline to post-module. Across the semester, student performance on simulations significantly improved on six out of eight patient-centered care skills.

SUMMARY

Students deepened their understanding of patient-centered care, grew in aspects of empathy, and improved actual and perceived ability to deliver care that is patient-centered during challenging encounters.

Addressing the Challenges of Providing Accommodations for Pharmacy Students With Disabilities Across Learning Environments

In accordance with the Americans with Disabilities Act of 1990 and the Accreditation Council for Pharmacy Education Standards 2016, schools and colleges are required to provide reasonable disability-related accommodations for eligible students enrolled in a Doctor of Pharmacy (PharmD) program. Strategies for providing reasonable and effective accommodations in didactic classrooms have been well defined. In contrast, PharmD programs often grapple with supporting learners requiring disability-related accommodations during skills-based laboratory and experiential learning performance assessments. A process that supports individualized accommodation planning, spans the breadth of the curriculum, aligns with course-level goals and learning objectives, and supports achievement of the 2013 Center for the Advancement of Pharmacy Education Educational Outcomes at the PharmD program level is essential to a student's successful academic progression. This commentary discusses challenges that arise when developing accommodation plans in patient-care skills laboratories and offers methods for bridging skills-based accommodation needs to experiential settings, while managing accommodations in an ever-evolving practice landscape.

Development of a scale to determine student self-efficacy in performing key pharmacists' patient care skills

BACKGROUND

The Pharmacists' Patient Care Process (PPCP) was developed to describe a consistent process in which pharmacists in any setting provide patient care. Faculty at a midwestern university developed and refined an assessment tool which provides an indirect approach to measure student confidence in performing skills essential to the PPCP. The objective of this paper is to conduct a stepwise factor analysis to refine the PPCP survey.

METHODS

Assessing appropriateness of survey response data led to an exploratory factor analysis (EFA) on student confidence data to refine the survey instrument and examine the underlying constructs that influence student responses. Post EFA, the results were presented to the research team that collaboratively reached consensus on inclusion or exclusion of items.

RESULTS

EFA factor loadings identified a 4-factor solution suggesting elimination of 30 items from the original 53 item survey. Team discussions led to eliminating 29 items, combining two items and generation of 5 new items in order to retain important concepts. The outcome was a well-conceptualized and refined 29 item-survey model assessing 4 constructs.

CONCLUSION

To potentially improve patient outcomes, it is imperative to utilize comprehensive yet concise survey instruments, like the PPCP Skills Self-Efficacy Survey, to prepare students to translate PPCP skills to practice.

A state-level needs analysis of community pharmacy point-of-care testing

Background

The uptake of point-of-care testing (POCT) within community pharmacies at state and national levels is largely unknown despite the endorsement and advocacy efforts of pharmacy organizations, recent legislative advances, and numerous models for successful POCT implementation within individual pharmacy sites.

Objectives

The study aimed to describe the current landscape of POCT in Wisconsin community pharmacies and identify opportunities for the advancement of testing and the key factors influencing the realization of these opportunities.

Methods

A survey was administered over the telephone to pharmacy managers of community pharmacies in Wisconsin. The sites were randomly selected from predefined geographic regions to mirror pharmacy distribution across Wisconsin. The survey items evaluated provision of POCT, future direction of POCT, barriers and motivators to offering POCT, and pharmacy demographics. Descriptive statistics and thematic analysis were used to analyze data.

Results

Pharmacy managers from 147 of the 938 registered community pharmacies (15.7%) participated in the survey. Only 17.1% of the pharmacies were offering POCT; however, 48.3% of managers reported that their pharmacy would likely implement or expand POCT within the next 5 years. The most commonly reported barriers to initiating or expanding POCT were the limitations on pharmacist availability to oversee testing and workflow restrictions. Continuing to advance the pharmacy profession was a top reason for offering or expanding testing services.

Discussion

While few pharmacies are offering POCT in Wisconsin, there is motivation for expansion in coming years. Understanding, anticipating and addressing common barriers can faciliate this process.

Conclusion

This needs analysis offers a blueprint for researchers, educators, and clinicians to shape POCT efforts by examining the landscape of pharmacy-based testing in their own states and communities.

Expert Consensus to Finalize a Universal Evaluator Rubric to Assess Pharmacy Students' Patient Communication Skills

Objective. To use an expert consensus-building process to develop a rubric used by multiple evaluator types to assess Doctor of Pharmacy students' patient communication skills.Methods. Faculty and staff members from six schools and colleges of pharmacy collaborated on a multi-step expert consensus-building process to create the final version of a communication rubric. First, faculty and patient content experts evaluated each item in the rubric for its relevance, criticality, and global comprehensiveness using a five-point Likert scale (0=not at all, 4=to a high extent). Descriptive statistics were used to analyze the resulting data. Faculty members evaluated the results and came to a consensus on the second version of the rubric. A corresponding codebook was developed and refined through a two-phase process.Results. The initial communication rubric was evaluated by 13 expert reviewers. Mean global comprehensiveness on the rubric was 3.83 for faculty experts and 3.5 for patient experts. After evaluating results from the expert consensus-building process, 14 items on the rubric did not change, five items were revised, three items were removed, and two items were added. The second version of the instrument included 20 items in six topic areas. A codebook was finalized to increase scoring consistency for the 20 communication items.Conclusion. Overall, content experts concluded that the rubric had high global comprehensiveness. Collaboration involving faculty members from multiple schools of pharmacy resulted in a 20-item communication rubric and codebook that can be used to increase consistency in scoring student pharmacists' patient communication skills.

Let External Stakeholders Be Your Guide to Curricular Revision

Schools and colleges of pharmacy undertake curriculum revisions for a variety of reasons ranging from the reactionary (eg, responding to changes in practice patterns, accreditation standards) to the proactive (eg, striving for innovation and excellence). Continuous quality improvement processes and published curriculum models, both described in this commentary, should be used to guide revision processes. Equally important is engaging the expertise of external stakeholders. While there may be challenges to incorporating external stakeholders in a curriculum revision process, their perspectives and knowledge can contribute to a more robust result, often in unexpectedly positive ways. Logic modeling is one mechanism to structure this approach, maximize the utility of external stakeholders, and strengthen the overall curriculum revision process. Regardless of the size of the revision, a good rule of thumb is to engage external stakeholders at the outset and to let their expertise be your guide.

Application of Absorb-Do-Connect learning framework to foster experiential, practice, and career-ready learners

INTRODUCTION

As educators, we have the opportunity to produce experiential-ready, practice-ready, and career-ready practitioners. Student attitudes and values influence how learned knowledge and skills will be enacted, and therefore are key determinants of career-readiness. However, attitudes and values can be challenging to see and measure in learners. In this commentary, the authors propose purposeful selection and application of an educational framework to foster those less tangible, but powerful, factors.

PERSPECTIVE

To illustrate this perspective, authors describe key components of the Absorb-Do-Connect learning framework and provide rationale for the framework's alignment with self-efficacy theory. The authors propose that Absorb-Do-Connect can be applied within pharmacy education to design learning activities that establish relevance in learning and subsequently foster self-efficacy through growth in attitudes and values.

IMPLICATIONS

The Accreditation Council for Pharmacy Education Standards emphasize connecting current education to past experiences and future practice to establish relevance in learning. In this manner, authors suggest Absorb-Do-Connect can be used by schools and colleges of pharmacy to inform new innovations and revise existing coursework to meet the standards. Opportunity exists to formally assess the relationship between absorbing, engaging with and purposely connecting knowledge and skills, and the development of self-efficacy in student pharmacists.

Development of a Holistic Assessment Plan to Evaluate a Four-Semester Laboratory Course Series

Objective. To implement a holistic assessment plan to evaluate the impact of a four-semester laboratory course series entitled Integrated Pharmacotherapy Skills on students' readiness to begin advanced pharmacy practice experiences (APPEs) following separation of the laboratory component from the Pharmacotherapy lecture component. Design. Faculty prospectively selected and employed a variety of course assessment methods including student self- and preceptor evaluation during APPEs, course evaluations, and a student confidence survey to evaluate student readiness for APPEs and ensure a quality learning experience for students. Assessment. APPE students' self-perceived confidence to perform skills increased after completion of the redesigned curriculum and after experiencing two APPE rotations. APPE preceptors did not report a change in student performance. Results from course evaluations suggest that separating the laboratory course from the lecture course created a positive learning experience for students. Conclusion. Students completing the new laboratory curriculum were equally prepared to begin APPE rotations as students who had completed the old curriculum. A similar multidimensional, holistic assessment plan could be used at other institutions to evaluate skills-based courses as part of continuous quality improvement.

Development and Application of a Stepwise Assessment Process for Rational Redesign of Sequential Skills-Based Courses

Objective. To develop and apply a stepwise process to assess achievement of course learning objectives related to advanced pharmacy practice experiences (APPEs) preparedness and inform redesign of sequential skills-based courses. Design. Four steps comprised the assessment and redesign process: (1) identify skills critical for APPE preparedness; (2) utilize focus groups and course evaluations to determine student competence in skill performance; (3) apply course mapping to identify course deficits contributing to suboptimal skill performance; and (4) initiate course redesign to target exposed deficits. Assessment. Focus group participants perceived students were least prepared for skills within the Accreditation Council for Pharmacy Education's pre-APPE core domains of Identification and Assessment of Drug-related Problems and General Communication Abilities. Course mapping identified gaps in instruction, performance, and assessment of skills within aforementioned domains. Conclusions. A stepwise process that identified strengths and weaknesses of a course, was used to facilitate structured course redesign. Strengths of the process included input and corroboration from both preceptors and students. Limitations included feedback from a small number of pharmacy preceptors and increased workload on course coordinators.

Pharmacist medication reviews to improve safety monitoring in primary care patients

OBJECTIVE

Patients prescribed psychotropic medications within primary care are at risk of suboptimal monitoring. It is unknown whether pharmacists can improve medication safety through targeted monitoring of at risk populations. Access Community Health Centers implemented a quality improvement pilot project that included pharmacists on an integrated care team to provide medication reviews for patients. Aims were to determine whether inclusion of a pharmacist performing medication reviews within a primary care behavioral health (PCBH) practice is feasible and facilitates safe medication use.

METHOD

Pharmacists performed medication reviews of the electronic health record for patients referred for psychiatry consultation. Reviews were performed 1-3 months following consultation and focused on medications with known suboptimal monitoring rates. Reviews were documented within the EHR and routed to the primary care provider. Primary outcome measures were change in percentage up-to-date on monitoring and AIMS assessment, and at risk of experiencing drug interaction(s) between baseline and 3 months postreview. Secondary outcome was provider opinion of medication reviews collected via electronic survey.

RESULTS

Reviews were performed for 144 patients. Three months postreview, percentage up-to-date on recommended monitoring increased 18% (p = .0001), at risk for drug interaction decreased 20% (p < .0001), and up-to-date on AIMS decreased 12% (p = .2113). The majority of surveyed providers wanted medication reviews to continue.

CONCLUSION

Pharmacist population-level monitoring within an integrated care team is feasible and associated with improved safety monitoring of psychotropic medications. Results identify key areas for improvement that other clinics considering integration of similar pharmacy services should consider. (PsycINFO Database Record

Impact of a Paper vs Virtual Simulated Patient Case on Student-Perceived Confidence and Engagement

OBJECTIVE

To evaluate online case simulation vs a paper case on student confidence and engagement.

DESIGN

Students enrolled in a pharmacotherapy laboratory course completed a patient case scenario as a component of an osteoarthritis laboratory module. Two laboratory sections used a paper case (n=53); three sections used an online virtual case simulation (n=81). Student module performance was assessed through a submitted subjective objective assessment plan (SOAP) note. Students completed pre/post surveys to measure self-perceived confidence in providing medication management. The simulation group completed postmodule questions related to realism and engagement of the online virtual case simulation. Group assessments were performed using chi-square and Mann Whitney tests.

ASSESSMENT

A significant increase in all 13 confidence items was seen in both student groups following completion of the laboratory module. The simulation group had an increased change of confidence compared to the paper group in assessing medication efficacy and documenting a thorough assessment. Comparing the online virtual simulation to a paper case, students agreed the learning experience increased interest, enjoyment, relevance, and realism. The simulation group performed better on the subjective SOAP note domain though no differences in total SOAP note scores was found between the two groups.

CONCLUSION

Virtual case simulations result in increased student engagement and may lead to improved documentation performance in the subjective domain of SOAP notes. However, virtual patient cases may offer limited benefit over paper cases in improving overall student self-confidence to provide medication management.

Simulated medication therapy management activities in a pharmacotherapy laboratory course

OBJECTIVE

To measure the impact of medication therapy management (MTM) learning activities on students' confidence and intention to provide MTM using the Theory of Planned Behavior.

DESIGN

An MTM curriculum combining lecture instruction and active-learning strategies was incorporated into a required pharmacotherapy laboratory course.

ASSESSMENT

A validated survey instrument was developed to evaluate student confidence and intent to engage in MTM services using the domains comprising the Theory of Planned Behavior. Confidence scores improved significantly from baseline for all items (p < 0.00), including identification of billable services, documentation, and electronic billing. Mean scores improved significantly for all Theory of Planned Behavior items within the constructs of perceived behavioral control and subjective norms (p < 0.05). At baseline, 42% of students agreed or strongly agreed that they had knowledge and skills to provide MTM. This percentage increased to 82% following completion of the laboratory activities.

CONCLUSION

Implementation of simulated MTM activities in a pharmacotherapy laboratory significantly increased knowledge scores, confidence measures, and scores on Theory of Planned Behavior constructs related to perceived behavioral control and subjective norms. Despite these improvements, intention to engage in future MTM services remained unchanged.